Use of National Electronic Health Record (EHR) Data Warehouse to Identify Inappropriate HbA1c Orders for Sickle Cell Disease Patient

The glycated Hemoglobin (HbA1c) test is one of the most important diagnostic and prognostic strategies for monitoring diabetes. However, the clinical utility of this test is questionable for sickle cell disease patients, who are homozygous for a variant hemoglobin gene (HBB). While there have been analyses from individual provider organizations, no prior national level analysis of the HbA1c ordering practice for sickle cell disease patients has been performed. A national level assessment could serve as a baseline to evaluate this quality concern in individual health care settings. The main objective of this study was to evaluate the frequency of the inappropriate HbA1c test orders and the prevalence of the more appropriate fructosamine test orders as an alternative to HbA1c test, nationally and at Truman Medical Center (TMC) in Kansas City, MO. We analyzed de-identified, HIPAA compliant, electronic health record (EHR) data in the Cerner Health Facts (TM) (HF) data warehouse. We identified the frequency of inappropriate orders of HbA1c tests by comparing the 526 Sickle cell patients in TMC with 36,625 sickle cell patients from 393 national facilities in the data warehouse. The linear unbiased percentages estimated from the Generalized Linear Mixed Model (GLMM) was used to rank the TMC with other national hospitals based on the percentage of sickle cell patients with inappropriate HbA1c test. TMC had a significantly higher percentage of sickle cell patients with HbA1c tests when compared to the national hospital cohort (32% versus 11%). The results showed that TMC ranks in the bottom 25% quartile of the 393 qualifying facilities with respect to inappropriate HbA1c orders. Interestingly, TMC sickle cell patients were ten-fold more likely to have at least one fructosamine encounter when compared to the sickle cell patients in the other 10 national hospitals which had fructosamine encounters (11% versus 1%). However, there was still a significantly higher number of sickle cell disease patients in TMC than in other national hospitals who had only HbA1c tests (24% versus 10%). These findings indicate that inappropriate HbA1c orders in sickle cell patients is a potential quality concern at TMC which can be addressed with sustainable interventions so that overtreatment or under-treatment of the diabetic condition in sickle cell patients are avoided.